| Payment ID | 112321 |
|---|---|
| Date Created | 06/23/25 10:08 am |
| Created By | Gloria Jimenez |
| Service Request | 110714 |
| Application ID | 96284 |
| Authorization Number | 226345 |
| Applicant Information | |
| Name | Brigett Essix |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16170604653 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Type of Service Request | Hotel Stay |
| Location | Delta Inn |
| Start Day | Monday |
| Guests | 1 |
| From | 06/18/2025 |
| To | 07/02/2025 |
| Days | 8 |
| Payment Details | |
| Payment Amount | $500.01 |
| Receipt Amount | $666.98 |
| Receipt Date | 06/18/2025 |
| Comments | hotel stay at the Delta Inn departure date is 07/02/25 |
| Receipt | |
| Staff Name | Gloria Jimenez |
| Case Manager | SJ |
| Case Worker Email | Email hidden; Javascript is required. |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 06/23/2025 |
